HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 338 BERRY STREET 12/13/2021 : Commonwealth of Massachusetts
City/Town of
s System Pumping Record •
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms may'be*used,but the
information-must be substantially the same as that provided here. Before using.this form,check with you
local Board of Health to determine the form they use.The System Pumping Record must be submitted tc
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left
Right side of buildin , Left/Right front of buildiri eft/ 'gh �f building, Under deck
on the computer,
use only the tab C/y
key to move your Addr s _
cursor-do not MA � ,
use the return i !t__0P,9own
key. State Zip Code
2. Syst m Owner:
(-r
11�ame
Bem
Address(if different from location)
MA
City/Town State 9� `. n✓ ^�ip od�
Telephone Numb/err fuj
B. Pumping Record '13 2�/
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) �ptic Tank ❑ Tight Tank ❑ Grea e Trap
P
❑ Other(describe):
4. Effluent Tee Filter present? ❑ YesJrNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Locati�n where contents were disposed:
GL Lowell Waste Water
Signature of Hauler Date